Product Liability Insurance - Chubb · 2019-08-23 · Have any insurer cancelled or refused to...

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Page 1 of 6 Important Notices Statement pursuant to Section 25 (5) of the Insurance Act (Cap. 142) (or any subsequent amendments thereof) - You are to disclose in this Proposal Form fully and faithfully all facts which you know or ought to know, otherwise the policy issued hereunder may be void. 1) Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty under the law to disclose to the insurer every matter within your knowledge that is material to the insurer's decision whether to accept the risk of the insurance and, if so, on what terms. If you are unsure whether a matter is material, you should disclose it. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. It is important that all information contained in this application is understood by you and is correct, as you will be bound by your answers and by the information provided by you in this application. You should obtain advice before you sign this application if you do not properly understand any part of it. Your duty of disclosure continues after the application has been completed up until the contract of insurance is entered into. 2) Non-Disclosure If you fail to comply with your duty of disclosure, the insurer may have the option of avoiding the contract of insurance from its beginning. If your non-disclosure is fraudulent, the insurer may also have the right to keep the premium that you have paid. 3) Claims Made Contract Subject to its terms and conditions, the policy will cover your legal liability for any claim: First made by you during the policy period; Resulting from any circumstance of which you become aware during the policy period which may give rise to a future claim against you, provided you immediately inform us in writing of such circumstances within the policy period. 4) Change of Risk or Circumstances You should advise the insurer as soon as practicable of any change to your normal business as disclosed in this application, such as changes in business activities, location, acquisitions and new overseas activities. 5) Subrogation Where you have agreed with another person or company (who would otherwise be liable to compensate you for any loss or damage which is covered by the contract of insurance) that you will not seek to recover such loss or damage from that person, the insurer will not cover you, to the extent permitted by law, for such loss or damage. Instructions to the Insured Before completing the proposal form, please read all important notices. This proposal should be answered after detailed enquiry of all persons to be covered. 1. Please type or print answers clearly. 2. Answer all questions completely, leaving no blanks. If any questions, or part thereof, do not apply, type or print ‘N/A’ in the space. 3. Provide any supporting information on a separate sheet using your Company’s letterhead and reference the applicable question number. 4. Check YES or NO answers. 5. This form must be completed, dated and signed by an authorised officer of your Company. Product Liability Insurance Proposal Form Proposal Form

Transcript of Product Liability Insurance - Chubb · 2019-08-23 · Have any insurer cancelled or refused to...

Page 1: Product Liability Insurance - Chubb · 2019-08-23 · Have any insurer cancelled or refused to renew your products liability coverage? ☐ Yes ☐ No If Yes, please explain. 20. Have

Page 1 of 6

Important Notices

Statement pursuant to Section 25 (5) of the

Insurance Act (Cap. 142) (or any subsequent

amendments thereof) - You are to disclose in

this Proposal Form fully and faithfully all facts

which you know or ought to know, otherwise

the policy issued hereunder may be void.

1) Your Duty of Disclosure

Before you enter into a contract of general

insurance with an insurer, you have a duty

under the law to disclose to the insurer every

matter within your knowledge that is material

to the insurer's decision whether to accept the

risk of the insurance and, if so, on what terms.

If you are unsure whether a matter is material,

you should disclose it. You have the same duty

to disclose those matters to the insurer before

you renew, extend, vary or reinstate a contract

of general insurance.

It is important that all information contained in

this application is understood by you and is

correct, as you will be bound by your answers

and by the information provided by you in this

application. You should obtain advice before

you sign this application if you do not properly

understand any part of it. Your duty of

disclosure continues after the application has

been completed up until the contract of

insurance is entered into.

2) Non-Disclosure

If you fail to comply with your duty of

disclosure, the insurer may have the option of

avoiding the contract of insurance from its

beginning. If your non-disclosure is fraudulent,

the insurer may also have the right to keep the

premium that you have paid.

3) Claims Made Contract

Subject to its terms and conditions, the policy

will cover your legal liability for any claim:

First made by you during the policy period;

Resulting from any circumstance of which

you become aware during the policy

period which may give rise to a future

claim against you, provided you

immediately inform us in writing of such

circumstances within the policy period.

4) Change of Risk or Circumstances

You should advise the insurer as soon as

practicable of any change to your normal

business as disclosed in this application, such

as changes in business activities, location,

acquisitions and new overseas activities.

5) Subrogation

Where you have agreed with another person or

company (who would otherwise be liable to

compensate you for any loss or damage which

is covered by the contract of insurance) that

you will not seek to recover such loss or

damage from that person, the insurer will not

cover you, to the extent permitted by law, for

such loss or damage.

Instructions to the Insured

Before completing the proposal form, please

read all important notices.

This proposal should be answered after

detailed enquiry of all persons to be covered.

1. Please type or print answers clearly.

2. Answer all questions completely, leaving

no blanks. If any questions, or part thereof,

do not apply, type or print ‘N/A’ in the

space.

3. Provide any supporting information on a

separate sheet using your Company’s

letterhead and reference the applicable

question number.

4. Check YES or NO answers.

5. This form must be completed, dated and

signed by an authorised officer of your

Company.

Product Liability Insurance

Proposal Form

Proposal Form

Page 2: Product Liability Insurance - Chubb · 2019-08-23 · Have any insurer cancelled or refused to renew your products liability coverage? ☐ Yes ☐ No If Yes, please explain. 20. Have

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Information About The Insured

1. Name Insured (Include all subsidiary companies)

a) _______________________________________________________________________________________________________________________________________________________________________________

b) _______________________________________________________________________________________________________________________________________________________________________________

c) _______________________________________________________________________________________________________________________________________________________________________________

Registered Address

_______________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________ Postal Code ______________________________

Tel No. _________________________________________________________________________ Fax No. __________________________________________________________________________________

Email _______________________________________________________________________________________________________________________________________________________________________________

2. Name Insured is

☐ Individual ☐ Partnership ☐ Corporation ☐ Joint Venture

3. Business of Insured is

☐Manufacturer ☐Distributor ☐ Importer ☐Other

4. Do you have a subsidiary, affiliate or representative office in the USA/Canada? ☐Yes ☐No

If Yes, please state the name(s), address(es) and relationship(s) of company(ies).

5. Have you acquired/merged with any other company in the last 10 years? ☐Yes ☐No

If Yes, please provide details and product range of the acquired/merged company.

6. a) Describe all products manufactured, processed, assembled or distributed by you.

b) How many years have you been manufacturing, processing, assembling or distributing these products?

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7. Are the products end products or component parts of an end product? Please state.

8. Are there any products which are no longer manufactured, processed, assembled or distributed by you? Please state when and why they

were discontinued.

9. Are there any new products proposed for reintroduction to the following territories in the ensuing year? Please tick where applicable.

USA / Canada ☐Yes ☐No

Europe / Australia & NZ ☐Yes ☐No

Rest of the World ☐Yes ☐No

If Yes, please list the products.

10. Are all of your products designed by you? ☐Yes ☐No

If No, please elaborate.

11. List all the products that are manufactured, processed, assembled or distributed by you. Please provide a breakdown of your sales

turnover (including domestic sales) to the 3 regions specified below (please specify currency).

a) USA / Canada

Product Next Year Current Year Prior Year 1 Prior Year 2 Prior Year 3

Total ($)

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b) Europe / Australia and New Zealand

Product Next Year Current Year Prior Year 1 Prior Year 2 Prior Year 3

Total ($)

c) Rest of The World

Product Next Year Current Year Prior Year 1 Prior Year 2 Prior Year 3

Total ($)

12. a) Do you enter into any contractual agreements that go beyond a typical purchase order agreement? ☐Yes ☐No

E.g. Hold harmless agreements or waivers of subrogation with importers/product purchasers?

If Yes, please describe and provide a copy of the contract.

b) Do you require cover for your vendors? ☐Yes ☐No

If Yes, please provide the details of vendors to be covered.

13. a) Describe all your internal and external quality control programmes / operations, as well as any tests conducted on the product(s).

Please include copies of these test reports.

b) If no product quality control is in place, how is your product quality determined?

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c) Is each product subject to and do they conform with applicable country of export or international ☐Yes ☐No

manufacturing and safety standards?

If Yes, please specify these standard(s).

14. Are records kept to trace all products? ☐Yes ☐No

15. Are appropriate and understandable instructions provided with the product(s)? ☐Yes ☐No

16. Are proper and adequate warnings and labels satisfying applicable standards affixed to the product(s) so that ☐Yes ☐No

potential users will understand the hazards associated with using the product(s)?

17. Are any product warranties supplied with the product(s)? If Yes, please describe or provide a copy. ☐Yes ☐No

18. What is the normal life span of the product(s)?

19. Have any insurer cancelled or refused to renew your products liability coverage? ☐Yes ☐No

If Yes, please explain.

20. Have there been any reported incidents or claims filed over any of your products in the last 5 years? Please provide details including

number of incidents, paid/outstanding amounts (please specify currency) and description of incident(s) for each year. If necessary, please

continue on a separate sheet with your company’s letterhead.

Year No. of Incidents Brief Description USA / Canada ($) Rest of The World ($)

Page 6: Product Liability Insurance - Chubb · 2019-08-23 · Have any insurer cancelled or refused to renew your products liability coverage? ☐ Yes ☐ No If Yes, please explain. 20. Have

© 2016 Chubb. Coverages underwritten by one or more subsidiary companies. Not all coverages available in all jurisdictions. Chubb® and its

respective logos, and Chubb. Insured.TM are protected trademarks of Chubb.

Published 08/2016 Page 6 of 6

Chubb. Insured.TM

21. Product Liability Limit(s) and Deductible(s) required

Limit ($ Million) Deductible

Option 1

Option 2

Option 3

Declaration

We have read and understood the Important

Notices contained in this application.

We agree that this proposal, together with any

other information or documents supplied with

this proposal, will form the basis of any

contract of insurance.

We acknowledge that if this application is

accepted, the contract of insurance will be

subject to the terms and conditions as set out in

the policy wording as issued or as otherwise

specifically varied in writing by the insurer.

We declare, after inquiry of all relevant persons

within our organisation, that the statements,

particulars and information contained in this

application and in any documents

accompanying this application are true and

correct in every detail and that no other

material facts have been misstated, suppressed

or omitted.

We undertake to inform the insurer of any

material alteration to those facts before

completion of the contract of insurance.

This form must be reviewed, signed and dated

by a duly authorised Principal or Director.

By signing this form, I/We hereby declare that

the above information provide by me/us or on

my/our behalf in the application and other

relevant information/document submitted for

this application are true and complete and

I/We agree that this application shall be the

basis of the contract between me/us and Chubb

Insurance Singapore Limited, otherwise the

policy issued may be void or voidable.

The insurance applied for shall only take effect

when the application has been approved by

Chubb Insurance Singapore Limited.

Signature of Proposer / Company Stamp

Name and Designation of Proposer

Date

Contact Us

Chubb Insurance Singapore Limited

Co Regn. No.: 199702449H

138 Market Street

#11-01 CapitaGreen

Singapore 048946

O +65 6398 8000

F +65 6298 1055

www.chubb.com/sg